Nursing Shift Report

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Hi all..I'm a new MedSurg RN, started in March. I work on a great floor and everyone is great and helpful, but I seem to be struggling with shift report. I always feel like I am fumbling or not giving enough information. I haven't received any poor feedback, but I always feel like it's an inadequate report. Any advice? ?

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Do you use an organized brain sheet? Be sure to update the sheet as you go throughout your shift that way you have the most and the most accurate information to give without forgetting anything.

It all gets better with time.

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My report, most done at the bedside....

This is Mr. Smith, 55yo male.

Admitted for chest pain, CA

Pmh: HTN, HPL, hypothydroid, smoker x 15 years

Dr. Johnson is attending

Procedures:

LHC: yesterday, 3 vessel disease

Cardiothoracic surgery consult for Bypass

Pt is currently free of CP with 1 inch of nitro 2% on left chest wall

AOX4, MAEW

2 Lnc

SB on Tele

Good pulses

Voiding

Nausea intermittent treated with Zofran prn

Last BM this morning

Up with standby to ad lib

20G left AC

CATH access: Right groin soft with small amount of bruising

Syvek patch and tegaderm c/d/i

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